The Egyptian Journal of Radiology and Nuclear Medicine (2016) 47, 291–295

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Egyptian Society of Radiology and Nuclear Medicine

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ORIGINAL ARTICLE

Diagnostic benefit of MRCP in

hepatopancreaticobiliary diseases in children

* Corresponding author at: 81 Mohy Eldeen Abdel Hameed, 8th

District, Nasr City, Cairo, Egypt. Mobile: +20 1001798342.

E-mail addresses: drnohaosman@yahoo.com (N.M. Osman),

shaimaa96@hotmail.com (S.A. Mohammad), rohamawad@hotmail.

com (R.M. Khalil).

Peer review under responsibility of Egyptian Society of Radiology and

Nuclear Medicine.

http://dx.doi.org/10.1016/j.ejrnm.2015.10.0120378-603X � 2015 The Authors. The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Noha Mohamed Osman *, Shaimaa Abdelsattar Mohammad, Reham M. Khalil

Department of Radiodiagnosis, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Received 1 September 2015; accepted 19 October 2015

Available online 11 November 2015

KEYWORDS

MRCP;

Pediatrics;

Jaundice;

ERCP

Abstract Objective: This study aimed at determination of the diagnostic benefit of MRCP as a

noninvasive method to evaluate the hepatopancreaticobiliary disorders in children.

Materials and methods: The study retrospectively enrolled 34 patients undergoing MRCP for sus-

pected hepatopancreaticobiliary abnormalities. MRCP findings were compared with other imaging

modalities, ERCP or operative findings.

Results: MRCP had overall sensitivity, specificity, and diagnostic accuracy of 93.5%, 100% and

94.1% respectively in detecting the etiology of hepatopancreaticobiliary diseases in our patients.

Positive predictive value was 100% while the negative predictive value was 62.5%.

Conclusion: MRCP is a fast, non-invasive method for diagnosing hepatopancreaticobiliary disor-

ders in children with high diagnostic accuracy, sensitivity and specificity. MRCP doesn’t involve the

use of ionizing radiation which is suitable for children. Thus, MRCP ought to be the standard diag-

nostic procedure in the future.� 2015 The Authors. The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting

by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.

org/licenses/by-nc-nd/4.0/).

1. Introduction

Today, Ultrasound (US) and magnetic resonance imaging(MRI) have become the preferred imaging modalities over

computed tomography (CT) in imaging of the pediatrichepatobiliary and pancreatic systems (1).

Besides being noninvasive, MRI has the advantages of

allowing detailed evaluation of the pancreaticobiliary tract

with a large field of view (FOV) and excellent patient toleranceproviding three-dimensional (3D) projection images likeendoscopic retrograde cholangiopancreatography (ERCP).Thus, MRCP has virtually replaced ERCP as the primary

investigative modality in all cases of obstructive jaundice notrequiring early endoscopic intervention (2).

Given its success in adults, MRCP has begun to be used in

children during the past decades; however, the pediatric litera-ture to date consists mostly of case reports and a few serialstudies focusing on particular clinical conditions. We therefore

designed this study in a series of pediatric patients undergoingMRCP in order to assess the diagnostic benefit of MRCP inhepatopancreaticobiliary diseases in children.

Fig. 1 Four-year-old girl presented with jaundice and abdominal

swelling. MRCP revealed huge cystic dilatation of the extrahepatic

biliary system (choledochal cyst Todani type I) (arrow) (a). Axial

T2WI shows multiple stones and mud are seen in its distal segment

(arrow) (b).

Fig. 2 Five-year-old girl presented with jaundice. MRCP shows

innumerable scattered, peripheral and intrahepatic liver cystic

lesions with high signal intensity. A case of Caroli disease.

292 N.M. Osman et al.

2. Materials and methods

2.1. Patients

This study took place from January 2013 to June 2015 in AinShams University Hospitals, Radiodiagnosis department. The

study was approved by the local ethics committee in AinShams University hospitals, and we retrospectively reviewedthe MRCP studies of 34 pediatric patients (16 males and 12

females) who were part of diagnostic workup for clinicallysuspected hepatopancreaticobiliary disease. Patients’ data

extracted from our database records included gender andage; medical history (including prenatal history if relevant,abdominal US, CT, isotope scan or ERCP findings, and any

surgery before MRCP or histopathological results); and clini-cal manifestations which included jaundice, clay-colored stool,abdominal pain, and abdominal swelling (Table 1).

All patients were subjected to abdominal US as a primaryimaging investigation. Eight patients had additional imagingstudies; CT was done for 5 cases and HIDA isotope scan for3 cases. Therapeutic ERCP was carried out for 3 cases. Upon

MRCP findings, fourteen patients out of 34 were candidatesfor surgical intervention.

In our study, we compared the MRCP results with those of

other imaging modalities; US in 9 cases, CT in 5 and isotopescan in 3 cases, ERCP in 3 cases or intraoperative findings in14 cases. We reviewed the MRCP examinations of all patients

in an attempt to display the benefit of MRCP in differentiatingthe different causes of hepatopancreaticobiliary pathologies inpediatrics and to find out its diagnostic accuracy.

2.2. MRCP examination

2.2.1. MRCP technique

MRCP examinations were all performed with a 1.5 T Achieva;Philips Medical Systems, Eindhoven, The Netherlands, byusing sense cardiac or sense body coil, depending on the body

size of patients. MRCP was performed as follows: coronal 3DFSE HR MRCP sequence (TR/TE:1100-1300/650) slicethickness 1.2 mm and 320 � 256 matrix size, with MIP post-

processing. Additional axial and coronal T2-weighted fastspin-echo and fat-suppressed sequence images were acquiredwith the following parameters: SSFSE repetition time/echotime of 300–550, 80–100 ms; slice thickness, 4 mm. The whole

Fig. 3 Seven-year-old girl presented with jaundice and colicky

abdominal pain. MRCP revealed dilatation of the intrahepatic

and the proximal extrahepatic biliary radicles with abrupt

obstruction (a). Coronal T2WI shows a stone within the proximal

CBD (arrow), and another stone is seen in the GB (arrowhead).

Fig. 4 Two-month male presented with jaundice. MRCP

revealed non-visualization of the extrahepatic central biliary ducts

and common bile duct. HIDA scan was positive for biliary atresia.

Diagnostic benefit of MRCP in hepatopancreaticobiliary diseases in children 293

examination lasted for 20–25 min. All images were acquired byuse of breath-hold technique in the older children if possible.In children who could not hold their breath, the MRCP exam-

ination was performed with respiratory triggering. The acqui-sition time for each sequence varied according to the patient’sbody volume and breathing rate. Patients fasted at least 6 h

before the examination. Sedation with oral chloral hydrate ata dose of 40 mg/kg of body weight (maximum, 1 g) was usedif the child was younger than 6 years or not able to cooperate

during the examination. In children older than 6 years pento-barbital (2–6 mg/kg, maximum 100 mg) was administeredintravenously. Sedation was administered by an Anesthesiolo-

gist following the American Academy of Pediatrics guidelines(3). Vital signs were monitored during the sedation, and allthe patients completed the examination smoothly, withoutany complications.

2.2.2. MRCP interpretation

MRCP images were analyzed and reviewed blindly and inde-

pendently by two pediatric radiology consultants of 10 yearsexperience. They were blinded to any other radiological ornon-radiological examination results.

2.3. Statistical analysis

The overall sensitivity, specificity, positive and negative predic-tive and diagnostic accuracy of MRCP in differentiating the

different hepatopancreaticobiliary pathologies were calculatedrelative to the final diagnosis using SPSS 20.0 (SPSS Inc.,Chicago, IL) software.

3. Results

The thirty-four patients (20 females and 14 males) in our study

series ranged in age from 1 month to 14 years (mean age:6.2 years). The clinical manifestations varied but jaundicewas the predominant presentation (Table 1). MRCP identified

the etiology of hepatopancreaticobiliary pathology in 29patients, all of whom were true positives (see Figs. 1–6).MRCP did not detect hepatopancreaticobiliary pathology in5 patients of which only 3 were true negatives (Table 2).

Patients with false negative MRCP results (2 cases) were foundto have CBD stones by ERCP.

Fig. 5 Five-year-old boy with history of Kasai operation

(portoenterostomy) (arrow) for biliary atresia, presented with

acute abdominal pain. MRCP and coronal T2WI revealed

segmental intrahepatic biliary radicles dilatations in hepatic

segment VII with areas of cystic dilatation (arrowheads), and

marked splenomegaly is also noted. Similar imaging findings were

reported by CT. The case was regarded as ascending cholangitis.

Fig. 6 Eight-year-old boy presented with chronic abdominal

pain and intermittent jaundice. MRCP shows dilated tortuous

main pancreatic duct and abnormal side branches (arrow) (a).

Coronal T2WI showing bulky pancreas with altered signals

(arrowheads) and dilated tortuous pancreatic duct (arrow) (b). A

case of chronic pancreatitis.

294 N.M. Osman et al.

In comparison with other imaging modalities, ERCP, oroperative results, we found that MRCP had overall sensitivity,

specificity, and diagnostic accuracy of 93.5%, 100% and94.1% respectively in detecting the etiology of hepatopancre-aticobiliary diseases in our patients. Positive predictive valuewas 100% while the negative predictive value was 60%.

4. Discussion

Relatively few studies of good quality have evaluated MRCP

in children, in part because of the relative rarity of such disor-ders in children. Most of publications studied MRCP exams inspecific entities commonly the diagnosis of choledochal cystsand biliary atresia.

Table 1 Clinical manifestations of our patients’ series (34

children).

Symptoms/signs No. (%)

Jaundice 28(82.3%)

Clay colored stools 11(32.3%)

Abdominal pain/tenderness 7(20.6%)

Abdominal swelling 3(8.8%)

Table 2 Final diagnosis of 34 children undergoing MRCP.

Final diagnosis No.

Choledochal cysts (Figs. 1 and 2) 4

CBD with/without GB stones (Fig. 3) 7

Biliary atresia (Fig. 4) 3

Calcular cholecystitis/GB stones 4

Acalculous cholecystitis 1

GB mucocele 1

Hepatic hydatid cysts 1

Postoperative biliary stricture 2

Postoperative ascending cholangitis (Fig. 5) 1

Pancreatic trauma 2

Pancreatitis (Fig. 6) 2

Negative pathology 3

Diagnostic benefit of MRCP in hepatopancreaticobiliary diseases in children 295

Tipnis and Werlin (4) cumulatively reviewed the literaturefor evaluating the role of MRCP in wide variety of hepatobil-iary disorders in pediatric patients; they stated that in 10 stud-

ies, MRCP produced 134 true positives, six false positives, 63true negatives, and 18 false negatives. Thus, the overalldiagnostic accuracy, sensitivity and specificity of MRCP for

hepatobiliary disease were 89%, 88% and 91% respectively.Positive predictive value was 96% and negative predictivevalue was 78%.

Uhm et al. (5) studied the role of MRCP in differentiating

hepatobiliary pathologies in 70 children. They declared thatthe overall diagnostic accuracy of MRCP was 97.1%.

Our study concluded that MRCP had overall diagnostic

accuracy, sensitivity and specificity of 94.1%, 93.5% and100% respectively in detecting the etiology of hepatopancreati-cobiliary disease in our patient series. Positive predictive value

was 100% while the negative predictive value was 60%.Our false negative patients were found to have CBD stones

at ERCP. The CBDs were dilated 5 and 6 mm in those cases.

Current literature states that the sensitivity of MRCP indetecting CBD stones decreases with bile duct dilatation (6).Our result agrees with those of Hurter et al. (7) who studied theaccuracy of MRCP compared with ERCP in the diagnosis of

bile duct disorders and concluded that MRCP had sensitivityof 87% in detecting bile duct calculi.

Over the past decade, MRCP has started to replace ERCPas the diagnostic study of choice for a variety of biliary andpancreatic conditions (8,9). Initially, MRCP was extremely

limited in its diagnostic accuracy and used sparingly in extre-mely cooperative patients. The advent of respiratory triggerand non-breath holding techniques gradually enabled MRCP

use in less cooperative patients, especially children (10). Con-currently, rapid imaging techniques including HASTE/single-shot FSE/single-shot turbo spin echo (TSE) decreased image

acquisition time to 2–5 s. Today, MRCP is utilized to studythe biliary system in almost all populations (8).

In conclusion, based on own experience, MRCP is a fast,non-invasive method for diagnosing hepatopancreaticobiliary

disorders in children with high diagnostic accuracy, sensitivityand specificity. MRCP doesn’t involve the use of ionizing radi-ation which is suitable for children. Thus, MRCP ought to be

the standard diagnostic procedure in the future.

Conflicts of interest and source of funding

None declared.

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